CHIEF COMPLAINT: Left elbow pain.
HISTORY OF PRESENT ILLNESS: Makayla is a very pleasant 4-year-old right-hand dominant female who presented to the emergency department yesterday after sustaining a fall while playing with another young family member. She fell onto an outstretched left arm and had pain in and around the left elbow. She was seen in the emergency department, where clinical and radiographic evaluations demonstrated the presences of a fracture through the left proximal ulna. The nurse practitioner who saw the patient asked that I evaluate the x-rays at that time. Those x-rays were seen and evaluated demonstrating an essentially a nondisplaced torus type fracture through the proximal ulna on the left without concomitant …show more content…
Lives with parent. She is here with her mother and grandmother. There is denial of second-hand tobacco.
REVIEW OF SYSTEMS: Review of systems with mother states there is no significant changes to the constitutional, integument, musculoskeletal and neurologic, cardiovascular, respiratory, gastrointestinal, genitourinary, or psychiatric systems other than those associated with the HPI.
PHYSICAL EXAM: The examination shows an apprehensive, anxious 4-year-old child who is conversant. She shows no evidence of head trauma and moves her head and neck through a range of motion without pain generation. She is nontender to palpation. Right upper extremity moves at the shoulder, elbow, wrist, and hand without limitation of bones, joints, or soft tissues. Neurologic and vascular tone are intact. Pelvis is stable. The patient is ambulatory and show no restrictions in motion at the hip, knee, ankle, or foot. Examination of the left upper extremity shows a posterior splint. This is removed and shows some mild swelling and ecchymoses in and around the posterior aspect of the elbow and ulnar forearm. Axillary, radial, median, and ulnar nerves are intact to motor and sensory tone. There is no evidence of vascular compromise. She is diffusely tender in and around the proximal ulna. Wrist motion is intact, though tender. Elbow motion is not stressed at this time, though visual monitoring of the child does show her with …show more content…
No concomitant injuries to the distal humerus or the radius are
HISTORY OF PRESENT ILLNESS: Makayla is a very pleasant 4-year-old right-hand dominant female who presented to the emergency department yesterday after sustaining a fall while playing with another young family member. She fell onto an outstretched left arm and had pain in and around the left elbow. She was seen in the emergency department, where clinical and radiographic evaluations demonstrated the presences of a fracture through the left proximal ulna. The nurse practitioner who saw the patient asked that I evaluate the x-rays at that time. Those x-rays were seen and evaluated demonstrating an essentially a nondisplaced torus type fracture through the proximal ulna on the left without concomitant …show more content…
Lives with parent. She is here with her mother and grandmother. There is denial of second-hand tobacco.
REVIEW OF SYSTEMS: Review of systems with mother states there is no significant changes to the constitutional, integument, musculoskeletal and neurologic, cardiovascular, respiratory, gastrointestinal, genitourinary, or psychiatric systems other than those associated with the HPI.
PHYSICAL EXAM: The examination shows an apprehensive, anxious 4-year-old child who is conversant. She shows no evidence of head trauma and moves her head and neck through a range of motion without pain generation. She is nontender to palpation. Right upper extremity moves at the shoulder, elbow, wrist, and hand without limitation of bones, joints, or soft tissues. Neurologic and vascular tone are intact. Pelvis is stable. The patient is ambulatory and show no restrictions in motion at the hip, knee, ankle, or foot. Examination of the left upper extremity shows a posterior splint. This is removed and shows some mild swelling and ecchymoses in and around the posterior aspect of the elbow and ulnar forearm. Axillary, radial, median, and ulnar nerves are intact to motor and sensory tone. There is no evidence of vascular compromise. She is diffusely tender in and around the proximal ulna. Wrist motion is intact, though tender. Elbow motion is not stressed at this time, though visual monitoring of the child does show her with …show more content…
No concomitant injuries to the distal humerus or the radius are